| Certificate Number | 401 | | Date Issued |
| Child Given Name | |
Humphrey | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 17 Jun 1882 |
Grant Twp Story Co IA | Place of Birth |
| Father's Given Name | Wm Harvey |
Humphrey | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Iowa | 27 | Father's Age |
| Mother's Given Name | Lucinda | Whitman | Mother's Maiden Name |
| Mother's Surname | Humphrey | Grant Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Pennsylvania | Mother's Birth Place |
| Mother's Age | 27 | 1 | Number of Child This Mother |
| Medical Attendant's Name | P.W. Farrar M.D. | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | P.W. Farrar M.D. | Nevada IA | Certificate Signer's Address |
| Returned by Name | P.W. Farrar M.D. | | |